Active surveillance (AS) aims to postpone or completely avoid local treatment of prostate cancer and minimise overtreatment and its associated morbidities without compromising survival. The increasing use of AS worldwide has been driven by robust evidence that AS in men with low-risk disease or even favourable intermediate-risk disease offers excellent cancer-specific outcomes while substantially reducing treatment-related morbidity 1. However, its applicability in men aged ≥75 years is uncertain, and therefore Kato et al. 2 provide us with valuable data from their nationwide, multicentre prospective cohort on AS in Japan. While metastases-free and prostate cancer-specific survival rates are reassuring, the uptake of AS in men aged ≥75 years also raises a more interesting fundamental question: is it really the right strategy for this population? The recently updated Prostate testing for cancer and Treatment (ProtecT) trial, which included men aged between 50 and 69 years (with more aggressive tumour characteristics), demonstrated that prostate cancer-specific mortality remains low regardless of treatment choice, while overall mortality is driven almost entirely by non-prostate cancer causes 3. Undeniably, in older patients, the absolute benefit of prostate cancer diagnosis, let alone structured surveillance, becomes even more marginal as health status and frailty determine life expectancy rather than tumour biology 4. Implementing AS strategies in the elderly population might rather lead to unnecessary costs and procedures (e.g. PSA testing, MRI examinations and prostate biopsies), while increasing the risk of overtreatment either by patient anxiety during surveillance or suspicion of tumour progression, which is very unlikely to be relevant at this age. This uncomfortable reality is demonstrated by the Prostate cancer Research International Active Surveillance (PRIAS)-JAPAN data: persistence on AS was very low in this older-age group, and many ultimately underwent active treatment, a large part even without proven evidence of disease progression. This off-protocol conversion to active treatment is well known but especially concerning in older men, as treatment-related side effects increase with age and comorbidity, while survival benefit is negligible 1. More emphasis on education and (mental) support seems necessary, as the authors state that Asian patients tend to experience greater anxiety regarding cancer progression. We strongly agree with the authors that an observation focused strategy is essential for low-risk disease in the elderly. Unfortunately, despite widespread adoption of AS, less is known about how or when AS should be de-escalated and later on converted into watchful waiting in an elderly population 5. Most contemporary AS protocols adopt a one-size-fits-all approach with frequent PSA measurements, DREs, MRI examinations and repeat biopsies. Especially for older men, protocols like these are burdensome, can negatively impact quality of life, and ultimately lead to unnecessary transition to active treatment. Research in the small subset of men aged ≥75 years, with excellent functional health status, in whom AS may still be appropriate, should focus on de-escalation and a timely transition to watchful waiting. Men who remain stable on AS for several years have a very low risk of metastasis and cancer-specific mortality, and transition from AS to watchful waiting should therefore be seen as a successful completion of AS and not as some form of failure 5. On the other hand, one can reasonably argue that AS is still preferable to immediate radical treatment and its inevitable side effects in men aged ≥75 years. Nevertheless the rationale of AS risks serious inflation in the elderly men through absence of meaningful benefit in prostate cancer-specific survival and high rates of unnecessary treatment conversion with loss of quality of life. However, in our opinion, this problem is not a fault of AS itself and should be seen in the broader picture of prostate cancer diagnostics in older men. Currently PSA testing policies that have made testing available to men upon request demonstrate an inappropriate age distribution with low rates of PSA testing in men in their 50s and excessive high rates among men aged >70 years. The recently published 23-year follow-up of the European Study of Prostate Cancer Screening demonstrated low absolute risk of death from prostate cancer, the high competing risk of death from other causes, and the limited potential for life years gained as compared with earlier screening in these older men 6. This conclusion is further supported by the fact that the absolute benefit of screening is minimal during the first 10 years but increases thereafter, showing the importance of long life expectancy in achieving a decrease in mortality. Diagnostic evaluation in these older age groups is thus leading to diagnoses that are least likely to matter and most likely to cause harm. Once labelled cancer, AS logically becomes the least aggressive management option. However, in an ageing society with increasing healthcare burden, we would be better served by avoiding diagnostics in these older age groups and reserving AS for carefully selected young and middle-aged individuals with the longest expected survival. Furthermore, more personalised risk-based AS tools in the near future will likely diminish unnecessary patient and healthcare burden and provide us with stronger data for de-escalation or timely transition to watchful waiting. The authors declare no conflicts of interest.
Mannaerts et al. (2026) studied this question.